Traumatic Injuries of Diaphragm

2. TRAUMATIC INJURY TO
DIAPHRAGM
DR FATIMA
PGT GENERAL SURGERY
DHQH

3. DEFINITION
• A TEAR IN THE DIAPHRAGM THAT ALLOWS THE ABDOMINAL ORGANS TO ENTER
THE CHEST CAVITY
• • TRANSFER OF ENERGY ACROSS THE DIAPHRAGM
• 1 PENETRATING BALLISTIC FRAGMENT
• 2 STAB WOUND
• 3 PRESSURE GRADIENT FROM COMPRESSIVE BLUNT TRAUMA

4. • 3MM THICK, DOME SHAPED
• • MUSCULOTENDINOUS
• • THREE PARTS -STERNAL, COSTAL & LUMBAR
• • SITE OF INSERTION AT THE CENTRAL TENDON
• • RIGHT DOME HIGHER THAN LEFT DOME
• • PIERCED AT THE CRURA BY IVC, ESOPHAGUS AND AORTA
• AT REST, RIGHT DOME IS AT ICS 4 AND LEFT DOME IS ~ 1 TO 2 CM LOWER MAXIMAL
INHALATION AT ICS 6 ON RIGHT AND ICS 7 ON LEFT

5. • • BLUNT TRAUMA TYPICALLY PRODUCES LARGE RADIAL TEARS MEASURING 5-15
CM, MOST OFTEN AT THE POSTEROLATERAL ASPECT OF THE DIAPHRAGM
• • IN CONTRAST, PENETRATING TRAUMA CAN CREATE SMALL LINEAR INCISIONS
OR HOLES, WHICH ARE LESS THAN 2 CM IN SIZE AND MAY PRESENT LATE AFTER
YEARS OF GRADUAL HERNIATION AND ENLARGEMENT.
• TEARS ARE USUALLY >10 CM, AND OCCUR IN THE WEAKEST PART,
MUSCULOTENDINOUS JUNCTION IN POSTEROLATERAL LOCATION

6. • SIGN AND SYMPTOM
• • EARLY – SHORTNESS OF BREATH
• – DYSPNEA
• – DECREASED BREATH SOUND
• – PARADOXICAL MOVEMENT OF CHEST WALL
• • LATE – ABDOMINAL PAIN
• – GUT OBSTRUCTION

8. • • SUSPECT DI IN PATIENT WITH
• – BLUNT INJURY
• • BLUNT THORACIC OR ABDOMEN INJURY
• • MULTIPLE FRACTURE LOWER RIB
• – PENETRATING INJURY
• • THORACOABDOMINAL AREA (T4-T12)
• • DELAYED PRESENTATION – HERNIATION OF ABDOMINAL ORGAN

10. INVESTIGATIONS
• CHEST XRAY
• NORMAL / NONSPECIFIC IN 20-50%
• MIGHT SHOW ELEVATED DIAPHRAGM
• GASTRIC OR COLONIC BUBBLE IN LEFT CHEST
• COILED NGT

12. CT SCAN
• FOLLOWING FINDINGS AS STRONG PREDICTORS OF BLUNT DIAPHRAGMATIC RUPTURE:DIRECT DISCONTINUITY OF
THE HEMIDIAPHRAGM MAY BE SEEN WITH OR WITHOUT INTRATHORACIC HERNIATION OF ABDOMINAL CONTENTS.
THE STOMACH AND COLON ARE THE MOST COMMON VISCERA TO HERNIATE ON THE LEFT SIDE AND THE LIVER IS
THE MOST COMMON VISCUS TO HERNIATE ON THE RIGHT SIDE.
• OTHER SIGNS OF DIAPHRAGMATIC RUPTURE INCLUDE:
• THE COLLAR SIGN (OR HOURGLASS SIGN) 3: A WAIST-LIKE CONSTRICTION OF THE HERNIATING HOLLOW VISCUS
FROM THE ABDOMEN INTO THE CHEST AT THE SITE OF THE DIAPHRAGMATIC TEAR, WHICH IS CLASSICAL FOR
DIAPHRAGMATIC RUPTURE
• THE DEPENDENT VISCERA SIGN: WHEN A PATIENT WITH A RUPTURED DIAPHRAGM LIES SUPINE AT CT
EXAMINATION, THE HERNIATED VISCERA (BOWEL OR SOLID ORGANS) ARE NO LONGER SUPPORTED POSTERIORLY BY
THE INJURED DIAPHRAGM AND FALL TO A DEPENDENT POSITION AGAINST THE POSTERIOR RIB
• 61% SENSITIVITY

13. THE MARGIN OF THE
LEFT DIAPHRAGM IS
NOT VISUALIZED.
BARIUM STUDY
SHOWS INTRATHORACI
C HERNIATION OF THE
STOMACH THROUGH
A LEFT
DIAPHRAGMATIC
RUPTURE (HOURGLASS
SIGN).

14. BOWEL LOOPS AND PART OF LIVER SEEN
OCCUPYING MUCH OF THE RIGHT
HEMITHORAX, SUGGESTIVE OF
DIAPHRAGMATIC RUPTURE

15. • *THE EVALUATION OF THE DIAPHRAGM BY
LAPAROTOMY IN THE ACUTE SETTING REMAINS
THE GOLD STANDARD FOR DIAGNOSIS

16. AIMS OF SURGERY
• CONTROL OF HEMORRHAGE AND SHOCK
• • CONTROL OF GI SPILLAGE
• • IDENTIFY ASSOCIATED VISCERAL INJURIES
• • REDUCE HERNIATED ABDOMINAL CONTENTS
• • ASSESS EXTENT OF DIAPHRAGMATIC INJURY
• • INSPECT THE THORAX
• • REPAIR

17. RATIONALE FOR EARLY REPAIR
• • LACK OF A HERNIA SAC ALLOWS THE HERNIATED VISCERA TO BECOME
ADHERENT TO THE THORACIC CONTENTS. - SURGICAL REPAIR IN CASES IN
WHICH THE DIAGNOSIS IS DELAYED OR THE REPAIR IS DEFERRED REQUIRES A
THORACIC APPROACH
• • ASSOCIATED ABDOMINAL INJURIES IDENTIFIED AND ADDRESSED
• • EARLY REPAIR REDUCES THE LIKELIHOOD OF RESPIRATORY COMPROMISE AND
LONG-TERM COMPLICATIONS ASSOCIATED WITH INCARCERATION AND
STRANGULATION OF THE INTRAABDOMINAL VISCERA.

18. SURGICAL TECHNIQUE
• EDGES GRASPED W/ ALLIS CLAMPS
• • SINGLE LAYER INTERRUPTED
• DOUBLE LAYER-HORIZONTAL MATTRESS
• • COMPLEX LACERATIONS (>5CM) - RUNNING SUTURE - MESH REPAIR (RARE) •
USE 0 OR 1 MONOFILAMENT SUTURES
• • TUBE THORACOSTOMY

21. MORBIDITY
• PNEUMONIA, EMPYEMA, SUBPHRENIC OR
INTRABDOMINAL ABSCESS
• DEHISCENCE, HEMIDIAPHRAGM PARALYSIS,
RESPIRATORY INSUFFICIENCY, PULMONARY
EMBOLISM

22. THANK YOU